CANCELLATION REQUEST / POLICY RELEASE - …

The ACORD name and logo are registered marks of ACORDPOLICY NUMBERCANCELLED POLICY INFORMATIONEXPIRATION DATEEFFECTIVE DATEPOLICY TERMEFFECTIVE date AND HOUR OF CANCELLATIONPMAMTIMECANCELLATION DATEINSURED NAME AND ADDRESSNAIC CODE: POLICY TYPECOMPANY NAME AND ADDRESSAGENCYCUSTOMER ID:SUB CODE:CODE:(A/C, No, Ext):PHONEPRODUCERCANCELLATION REQUEST / POLICY RELEASEDATE (MM/DD/YYYY)This representation is true and accurate, and I understand that any misrepresentation may be deemed a fraudulent act.(Not applicable in NH per RSA 412:5 I)DATETITLEAUTHORIZED SIGNATUREPOLICY RELEASE (Complete Statement Section Below) CANCELLATION REQUEST ( POLICY attached)Any premium adjustment will be made in accordance with the terms and conditions of the this POLICY for losses which occur after the date of CANCELLATION shown claims of any type will be made against the Insurance Company, its agents or its representatives,The above referenced POLICY is lost, destroyed or being undersigned agrees that: POLICY RELEASE STATEMENTDATEWITNESSDATEWITNESSDATESIGNA TURE OF NAMED INSUREDDATESIGNATURE OF NAMED INSUREDLOSS PAYEEMORTGAGEELIENHOLDERLOSS PAYEEMORTGAGEELIENHOLDER(Not applicable in NH per RSA)

The ACORD name and logo are registered marks of ACORD POLICY NUMBER CANCELLED POLICY INFORMATION EFFECTIVE DATE EXPIRATION DATE POLICY TERM EFFECTIVE DATE AND

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